The hospital industry in the United States is being dramatically reshaped through consolidation of hospitals into regional and local health networks and systems, with 80 percent of the industry in a system or network by 1996. There is a belief, supported by a number of case studies, that the increasing role of managed care delivery systems, and particularly the increasing use of Medicaid managed care by states, has led to a shift of private and Medicaid patients away from at least some hospitals serving the medically indigent, potentially leading to increasing financial insolvency and possibly to shifts in mission by these hospitals. Our proposed research study will investigate three interrelated questions that together will reveal the evolving role of safety net hospitals in metropolitan statistcs areas (MSAs) across the United States and the subsequent impact on patient populations: Research Question 1: Under what circumstances are safety net hospitals participating in local and regional health networks and systems and when are they excluded? When included, what types of health networks and systems do they participate in? Research Question 2: How has the growth of Medicaid managed care affected the patterns of care for patients who have traditionally relied on the safety net, specifically the uninsured and Medicaid patients, and how has safety net hospital inclusion in (or exclusion from) health systems and networks influenced these patterns? Research Question 3: How has the inclusion in (or exclusion from) health systems and networks affected the cost, financial health, and survival of safety net hospitals?